The URL can be used to link to this page

Home My WebLink About2025-26Docusign Envelope lD 8E4 1A47846A3 oh.Nlo. l1ONqAbT n? ?l HEA11H TOWN OI- YARMOUTH BOARD OI' HEALTH 2025/2026 HANDLING AND STORAGE OF TOXIC OR HAZARDOUS MATERIALS LICENSE APPLICATION COMPLETE THIS APPLICATION AND RETURN TT WITH THE LICENSE FEE BY JI'NE 30, 2025 LTcENSE FEE $r5o 6HHt{-auJ-a t €sc*lliriu EPTD PLEASE COMPLETE AIL OUESTIONS NAME OF BUSINESS Federal Express corporation BUSINESS TEL. # 412-8s9-2384 BUSINESS ADDRESS tN YARMOUTII 225 white's Path, Units 2 & 3, South Yarmouth, MA 02664 BEOIIIBED MANAGER/CONTACT PERSON Evan cuci TELEPHO NF, # 774-779-7908 (lwNl;t{ NAt\4tl 225 White's Path tLc TF.L.# 7819A7-3547 HOME ADDRESS 231 willow Street, Yarmouthport, MA 02675 CORPORATION NAME (IF APPLICABLE)-TEL. # CORPORATION ADDRESS MAILING ADDRESS 71-0427001 LICENSES RUN ANNUALLY FROM JULY I TO JUNE 30. IT IS YOT]R RESPONSIBILITY TO RETURN THE COMPLETED APPLICATION(S) AND REQUIRED FEE(S) BY JLTNE 30. FAILURE TO DO SO WLL RESULT IN CLOSURE OF YOUR ESTABLISHMENT UNTIL THE REQUIRED APPLICATIONS(S) AND FEE(S) ARE RECEIVED. A HEARING BEFORE THE BOARD OF HEALTH MAY BE REQLIRED PRIOR TO RTiOPI.]NING. Town of Yarmouth taxes and liens must be paid prior to renewal or issuanc€ ofyour permits. Please check appropriatcly ifpaid: yes_ no_ nla- Undcr Chapter 152, Sec. 25C, subsection 6, the Town of Yarmouth is required to hold issuance or renewal of any license or permit to operate a business ifa person or company does not have a Certification of Workers Compensation insurance. As part ofthe renewal or issuance ofyour permits, you must completc the enclosed Workers Comoensation Affidsvit. Ifnot aDDlicablc. oleasc cxolalo APPLICANT'S SIGNATI]RE fraa^- (rtL DATE 6/t6/202s JUt MAILING ADDRESS 1(x)0 FedEx orive, Attn: Environmental Dept., Moon Township, PA 15108 EMAIL ADDRESS environmental@fedex.com rAx rD (FEIN oR ssN)BEQUIIIUU REGISTRATION FORM SIGNED AND COWLETED CHECK AND WORKERS COMP AFFIDAVIT ENCI,OSED YN ALL SAFETY DATA SHEETS ONFILE YN ANY NEW CHEMICALS MUST BE PRf,-APPRO!'ED BY TEE HEALTH DEPARTMENT. RENEWALAPPLICATION- NEWAPPLICATION- Docusign Envelope lD: 8E4OA53G.27F7-4DFB-89C+894 1A47846A3 The Commonwealth of Massachusetls Deparlrrrent of I ndustrial Accide nts Ofice of Investigations Lafay*e City Center 2 Avenue de Lafayette, Boston, MA 02111-1750 www.mass.gov/dia Workers' Compensation Insurance AIfidavit: General Businesses Anolicant Information Please Print Lesiblv Business/0rg anization Name: Federal Express corporation CitylStilelZip: Moon Township, PA 15108 Are you rn employer? Check the sppropriate box: 1.fr I am a employer with or part-time).* 2. ! t am a sote proprietor or partnership and have no employees working for me in any capacity. [No workcrs' conrp. insurance required]3.I We are a corporation and its oflicers have exercised their right ofexemption p€r c. 152, $ l(4), and we have no employees. [No workers' comp. insurance required]*t4.! We are a non-profit organization, staffed by volunteers, with no crnployecs. [No wo*ers' comp. insurance req.] s00 employees (full and/ Phonc #: 4t2-ass-23a4 Budness Typc (requlred): 5. E Retail 6. ! RestauranVBar/Eating Establishment 7. ! Office and/or Sales (incl. real estate, auto, etc.) 8. I Non-profit 9. E Entertainment 10.I Manufacturing I LE Healrh CarcnvOther parkagcrielivprv 'Any applicant that chccks box * I must also lll I out the section below show ing $cir workers' co pensation policy informa(ron. organization should chcck box #l. I am an employer thal is proyiding workers' compenselion insarancclor ny employees. Below is lhc policy inlornatiott lnsurancc Company Name: lndemnity Insurance Company of North America Insurer's Address: 1601 Chestnut Street CitylstatelZip Philadelphia, Pennsylvania 19192 Policy # or Self-ins. Lic. # W1RC72624129 Exp iration Date : 0 2026 Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration dste). Failure to secure coverage as required under ti 25A ofMGL c. 152 can lead to the imposition of criminal penaltics ofa fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form ofa STOP WORK ORDER and a fine ofup to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the OIIc€ of Investigations of the DIA for insurance coverage verification. I do hereby certify, ander the pains and penaltics o! perjury ,hs, the inlon ation provided above is true and correcl 6urt- (NL 6/L6/202s Date Phone #472-859-2384 Oflicial use only. Do not i'ite in this arcs, to bc contpleud b! city or towfi ollicisl CitY or Towa: - Permit/Llcense # Department 3.E Cityflown Clerk 4.Elicensing Board lssuing Authority (check one): lflBoard of Heatth 2.ftBuilding 5D Sel€ctmen's Oflice 6. Eother PhoDe #:Coutact Person: www.mass,gov/dia Address: looo FedEx Drive, Attn: Environmental oept.